AFFIDAVIT OF INDIGENCY I, , do solemnly swear or affirm under penalties of perjury, that owing to poverty, I am not able to bear the expense of the furnishing of my medical record(s), and that any future action will be filed with the Court, along with a Pauper's Oath, pursuant to Tennessee Code Annotated, §20-12-127. I am, am not, represented by an attorney and this is my first request for any or all of my medical record(s). Signature of Patient Date: Birth Date: Social Security Number: State of Tennessee County of Subscribed and sworn to before me, this day of , 20 . By: Notary Public
Click to view AFFIDAVIT OF INDIGENCY
- Notwithstanding subdivision (a)(2)(A), a hospital may not impose a charge on an indigent person for furnishing the person, or the person's attorney or authorized representative, with a health record or part thereof concerning the patient for the purpose of supporting a claim or appeal under any provision of the Social Security Act, compiled in 42 U.S.C. § 301 et seq., if a request for the record or part thereof is accompanied by a copy of a recent application seeking benefits under the Social Security Act or a copy of a recent decision denying benefits. Patients being represented by organizations whose purpose is to provide legal assistance to the indigent, or represented by attorneys with an affiliated pro bono program, shall be presumed indigent. A hospital may demand reasonable proof of indigency from any other patient not so represented, or the patient's attorney or authorized representative, by submission of the following form:
- If a copy of the patient's medical records has been previously provided without charge to an indigent patient or the patient's attorney or authorized representative, the hospital is not required to provide an additional copy of the same records without charge. A hospital shall furnish a health record requested pursuant to this section within thirty (30) days of the request.